Leveraging Utilization Management to Control Costs and Ensure Quality Care

Utilization management aims to balance quality care with increasing healthcare costs. Traditionally, utilization management has been seen simply as a cost saving measure. However, providers are no longer incentivized simply on service volume – outcomes-based measurements mean the quality of service is of equal importance.

Manual utilization management processes have difficulty achieving both volume and quality.

Through harnessing the capabilities and tailored solutions of Salesforce, digital transformation enhances every phase of the utilization management lifecycle to the benefit of providers, payers, patients, and members.


Manual processes, risk of error, and costs associated with authorizations that either delay or deliver unnecessary care


A utilization management platform that connects payers, providers, and members with the data they need


Streamlined provider authorization requests, faster clinical decisions, and less manual tasks

Solving the Use Case


First of all, we generally configure two role and permission sets in Salesforce to achieve this use case. They are:

These roles will be used throughout a high level utilization flow that we customize in Salesforce. These are:

In the next sections, we'll explain how we configure a variety of Salesforce products to provide a streamlined workflow for every step.

Meeting the Requirements

Needs Assessment and Authorization

For even more provider convenience, we leverage OmniScript process libraries that give providers a guided workflow for needs assessment. This means less errors when updating an EHR record and utilizing payer-specific diagnostic codes.

In reality, providers have different ways they prefer to authorize care. We create a variety of request management options that work seamlessly with Salesforce Health Cloud.

Although considered outdated, these options retain their importance in meeting every provider's needs. However, for a more effective solution to utilization management, EHR integration is key.

In this scenario, we leverage Mulesoft Direct to empower providers in utilizing existing patient data from their EHR. Providers can then submit this data, alongside an authorization request, in Da Vinci FHIR API format to a payer's FHIR endpoint using a Mule Connector. The outcome is an authorization process that significantly reduces manual data entry, eliminates errors, and saves time.

Example of digital provider applications

Intake Management

During intake management, specialists manually enter details from authorization requests in order to verify eligibility, confirm benefits, and route them to clinical review. This process introduces many points of risk for human error.

But the process can be improved in Salesforce.

To reduce the amount of manual work, we configure rules that automate authorization requests to appropriate clinical resources based hours, skills, line of business, or other criteria. This is where Salesforce's declarative workflows shine.

Clinical Review

In traditional processes, clinicians didn't have a way to access medical necessity criteria in a central location. As a result, they needed to spend countless hours tracking down documentation across disparate systems.

Because Salesforce centralizes data, we're able to display all relevant medical necessity criteria into a single dashboard. This data can be sorted by a variety of parameters, including SLA Due Date, requesting provider, status, and more. Furthermore, cases can be quickly escalated to medical directors, nurses, or other staff, ensuring consistency and efficiency.

Decision and Communication

The streamlined data allows for quicker decision-making, with medical directors having access to a wealth of information for more informed choices.

After a decision is reached, we leverage Salesforce's declarative workflows to initiate communication upon closure of authorization requests via email. These messages are sent to both the provider and the member, ensuring consistent, prompt, and well-considered responses.

Furthermore, responses can be tailored based on various factors such as decision type, nature of condition, or other relevant data points, significantly reducing the chance for complaints, grievances, or appeals.

Streamlined Processes

Seamless authorization from request to decision

Lower Costs

Provide the right care at the right time

Less Manual Tasks

Eliminate wasted effort with automated rules

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